Provider Demographics
NPI:1073396719
Name:BEDUDOORI, REVATHI
Entity Type:Individual
Prefix:
First Name:REVATHI
Middle Name:
Last Name:BEDUDOORI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9750 MASPALOMAS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89178-7512
Mailing Address - Country:US
Mailing Address - Phone:702-481-9763
Mailing Address - Fax:
Practice Address - Street 1:9750 MASPALOMAS ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89178-7512
Practice Address - Country:US
Practice Address - Phone:702-481-9763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV862399363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care